Today we look at tumours very closely to understand the driving force behind the cancer : Dr Colin Phipps

There has been a lot of progress in designing treatments that can specifically target these cells. Specific targeting means that we can now hone in on the blood cancer cells that we want to kill precisely.Shahid Akhter | ETHealthWorld | April 23, 2018, 16:48 IST

Q: What are the recent advancements in blood cancer? There have been recent advancements in both diagnostics as well as treatment. This has grown in parallel, because improved diagnostics allowed us to classify blood cancer in a very detailed way by identifying exactly what type of cells are in the blood cancer itself. And there are so many types of blood cells that can become cancerous. The advancements have also allowed us to look at tumour very closely so that we know what is driving the cancer’s growth. We can also detect the surrounding cells that are promoting blood cancer’s survival, the genes and mutations that helps the cancer grow and survive despite treatments and our own immune defences trying to kill the blood cancer.

Because of the advance treatments, we know that what cells we are dealing with. There has been a lot of progress in designing treatments that can specifically target these cells. Specific targeting means that we can now hone in on the blood cancer cells that we want to kill; targeting also means that a lot of cells in the body are spared unlike chemotherapy. The problem with chemotherapy has been that it not only targets the cancer cells but other cells that grow quickly like our hair follicles and our bone marrow cells, which also get affected eventually. This is where targeted therapy has really changed things. Hence, patients who are not able to withstand the toxicity of chemotherapy can receive effective treatments by way of these targeted therapies.

Q:How has bone marrow transplantation transformed over the years ?Modern day bone marrow transplantation started in the late 1950s and 1960s when it was considered experimental. The main role of bone marrow transplantation is basically to kill residual cancer cells, specifically for blood cancers which are in a setting of acute leukaemia. At that time, the bone marrow sauce was from a matched brother or sister, given directly from the bone marrow.

Over the time, advancements happened which improved the outcomes in general. The first was the ability to match the patient and the donor very well; so that when the donor cells entered the patient’s body, it did not cause too much problem. It was also important that the patient’s body did not reject the donor’s cells.

The second advancement is how we harvest blood stem cells. Today, more than 97% of the time it is taken from the blood stream, wherein, most of the donors do not need to undergo harvesting directly from the bone marrow. Another important advancement has been our ability to increase donor pool.

As I said, in the past the donor had to be only siblings, but now, we can get the donor cells from a matched adult who is unrelated because of the proliferation of stem cell banks or registries around the world. If we do not succeed in getting a donor, we still have the option of clot blood cells. The clot blood cells are in parallel to the proliferations of clot blood banks around the world. In Singapore, we have our own clot blood bank.

If we still cannot find a donor, we can undergo bone marrow transplant using a half matched donor which is - parents or children.

Q: Please elaborate on advanced treatment in lymphomaFor lymphoma in particular, there has been a boom in the use of targeted therapy which is in line with our knowledge about what type of lymphoma we are dealing with, the genes, and the survival pathways that promote the growth of these lymphomas. Today, there are about 60+ subtypes of lymphoma as opposed to 30 years ago when we could tell about the type of lymphoma based on what we saw under the microscope. But now there are 60+ sub-types, as we know exactly how to look for the lymphoma cells by using techniques like flow cytometry, advanced immunohistochemical staining, molecular techniques and next generation sequencing.

Q: Please tell us a out stem cell transplantation at Parkway Cancer Centre White stem cell transplantation is a journey for the patient; it is an intense multi-disciplinary approach for us. Starting from the time the patient arrives, to find a donor for the patient, match the patient to that donor, and wake the patient up subsequently, it is a step by step process. The multi-disciplinary care starts before the transplant wherein, the patient needs to be counselled about infectious disease prevention and about the importance of adequate and clean nutrition. We also need to tell the patient what to expect before, during and after the transplant period. We also apprise them about their disease, whether they will stay in remission and so on.

For transplant at Parkway Cancer Centre, we have a transplant ward. A transplant ward is very important because transplant patients are transplanted in positive pressure and laminar flow rooms. This means that, all the time air is being pushed out from the rooms so that there is no ‘Dirty Air’ flowing from the corridors into the patient’s room. Now that is extremely important for reducing the rates of infection.

The other thing about the multi-disciplinary approach is that the infectious disease protocols are also crafted together with our infectious disease team.

Q:Your thoughts on blood cancer immunotherapyImmunotherapy is basically using the patient’s own immune system or components of the immune system to fight blood cancer. It started with very primitive medications; moved onto allogeneic stem cell transplantation which is one of the oldest and most well-known forms of immunetherapy. In this kind of stem cell transplantation, the donor cells injected into the patient are able to recognize the patient’s cancer cells and have great potential to kill those cancer cells. That has been the oldest and most time-tested form of immuno therapy in blood cancer.

But now-a-days, medications are equally important. We have what we call the mono chrono antibodies that specifically recognize proteins on different blood cancer cells and can target and kill them. Mono chrono antibodies are one of the mainstays of immuno therapy in blood cancer, especially in lymphoma.

We also have check-point inhibitors which are able to invigorate a patient’s own immune system and kill the cancer cells. The other form of immuno therapy that is really up coming in this region is chimeric antigen receptor T cell therapy or chi T cells which are basically antibodies harvested from the patient and modified in the lab. When this is given back to the patient they can recognize the blood cancer cell and lead to good killing of the cancer cells.